Western ideals and global realities – physiotherapists’ views on factors that play a role in ethical decision-making: an international qualitative analysis

Figures & data

Table 1. Glossary of terms.

Ego strength is a concept derived from psychoanalytic theory and is related to strength of convictions or self-regulatory skills. Individuals high in ego strength are likely to do what they think is right [18,19].

Ethical decision-making includes recognising an ethical situation, making professional ethical judgements, establishing a moral intent and implementing ethical actions/engaging in ethical behaviour [15] An ethical decision is a decision that is both legal and morally acceptable to a larger community [20,p.367].

Ethical principlism is a consequential theory widely applied in healthcare professions’ code of ethics. Beauchamp and Childress reviewed existing (Western) philosophical approaches, and organised them into the four biomedical key principles autonomy, non-maleficence, beneficence and justice [28,29].

Epistemology refers to the nature and scope of knowledge. It includes an understanding of the limitations of different forms of knowledge, and how knowledge is created in certain social, historical and cultural contexts from which the knower cannot be removed [27].

Field dependence is a psychological trait associated with an external locus of orientation. Field-dependent persons are more affected by a lack of structure in the environment as other persons. Field-independent individuals use an internal frame of reference and can impose their own sense of order in a situation that is lacking structure; they also function with greater autonomy in social settings [19,21].

Locus of control is a psychological concept that refers to an individual’s perception of how much control they exert over events in life, or the causes of their successes or failures. Locus of control can be external or internal [18,19].

Mentalising ability is the ability to attribute mental states (such as beliefs, desires and intentions) to oneself and others. It is needed in order to understand and predict other people’s behaviour, and therefore it is thought to influence all human social interaction [22].

Moral agency is a person’s ability to make moral judgments based on commonly held notions of right and wrong, to act morally on behalf of others and to be held accountable for these actions [24].

Moral agent is a person who is capable of deliberating, thinking, deciding and acting in accordance with personal and professional moral standards and principles [1].

Moral courage involves implementing the chosen ethical action, including the development a plan and perseverance in the face of barriers and adversity [15].

Moral judgement requires deciding on right versus wrong actions. This process involves generating options, selecting and applying ethical principles [15].

Moral motivation places a priority on ethical values over other values, such as self-interest, status or financial gain. Professionalism is a primary ‘motivator’ for ethical behaviour [15].

Moral sensitivity involves recognising, interpreting and framing ethical situations [15].

Professional codes of ethics or codes of conduct are formalised and expected standards of professional behaviour and values within a profession and are usually developed by a professional association or governing body [4].

Professional (ethical) responsibility is defined within professional codes of ethics, and can be seen as a reaction to human vulnerability. Healthcare has a moral dimension that inherently requires responsibility to ensure patient’s safety, their best interest and centrality [13,23,25].

Professional values guide daily practice and professional behaviours. They clarify what professionalism means to a profession, by providing insight into the values that members of the profession aim to uphold and profess [26].

Table 2. Description sample by gender, age, occupation, religion, ethics education, and geographic regions.

	N or M (SD)	N or M (SD)	N or M (SD)
Characteristic	Reports	Nothing more to add	Total
Gender
Female	127	11	138
Male	58	3	61
Diverse/other	1	0	1
Age (years)
M (SD)	38.59 (12.49)	40.64 (13.30)	38.73 (12.45)
≤35 N	91	6	97
>35 N	94	8	102
Years of practice
M (SD)	13.86 (12.03)	15.73 (10.78)	13.98 (11.98)
N	185	13	198
Different fields of practice (currently or over lifetime)
M (SD)	5.41 (3.13)	5.57 (2.65)	5.42 (3.04)
Religion
Christianity	72	9	81
Islam	19	0	19
Hinduism	25	1	26
Buddhism	6	0	6
Secular/Nonreligious/Agnostic/Atheist/Irreligious/Unaffiliated	54	3	57
Ethnic and indigenous religion	0	0	0
Sikhism	0	0	0
Juche	0	0	0
Spiritism	1	0	1
Judaism	0	0	0
Baha’i	0	0	0
Jainism	1	0	1
Neo-Paganism	1	0	1
Unitarian	1	0	1
I don’t want to share this information	5	1	6
Other	1	0	1
Total	186	14	200
Learned about a professional code of conduct/code of ethics
No	20	2	22
Yes, during my basic physiotherapy education	100	7	107
Yes, in a graduate or post-graduate program	39	4	43
Yes, in a professional ethics course	16	1	17
Yes, by learning about professional ethics on my own	8	0	8
Yes, by learning about professional ethics from others	2	0	2
Don’t know	1	0	1
Other	0	0	0
Total	186	14	200
Learning sources M (SD)	1.47 (1.07)	1.29 (0.83)	1.46 (1.05)
Learned about specific ethical decision-making/or ethical reasoning frameworks
No	40	3	43
Yes, during my basic physiotherapy education	80	8	88
Yes, in a graduate or post-graduate program	38	2	40
Yes, in a professional ethics course	16	1	17
Yes, by learning about professional ethics on my own	10	0	10
Yes, by learning about professional ethics from others	1	0	1
Don’t know	0	0	0
Other	0	0	0
Total	185	14	199
Learning sources M (SD)	1.35 (1.11)	1.07 (0.83)	1.33 (1.03)
Geographic region	N of participants in survey	N of participants who responded to Q44 (%)*	N of participants who responded to Q44 with data for analysis (%)*
Africa	57	28 (49.1)	24 (42.1)
Asia Western Pacific	151	60 (39.7)	58 (38.4)
Europe	273	86 (31.5)	80 (29.3)
North America Caribbean	63	26 (41.3)	24 (38.1)
South America	11	0 (00.0)	0 (00.0)
Total	555	200 (36.0)	186 (33.5)

*Percentage calculation based on total number of participants from each region.

N: total number of participants or participant responses; M: mean value; SD: standard deviation; Q44: optional open question at the end of the survey.

Figure 1. Qualitative analysis of data by using elements of coding reliability thematic analysis and reflexive thematic analysis.

Figure 2. Individual situatedness of the three researchers.

Figure 3. Five themes of factors identified in ethical decision-making of physiotherapists internationally.

Figure 4. List of themes and factors in ethical decision-making of physiotherapists internationally. (* = these factors include subcatgories)

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Data availability statement

The data that support the findings of this study are available on reasonable request from the corresponding author, AS. The data are not publicly available due to ethical restrictions to protect the research participants who provided sensitive information.